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ENJOY A VARIETY OF FOODS —                                          There are several diet-related public health concerns in South
                                                                    Africa. Food-Based Dietary Guidelines (FBDGs) have been
DIFFICULT BUT NECESSARY IN                                          proposed to attempt to resolve many of these public health
DEVELOPING COUNTRIES                                                problems.1 As outlined in the introductory paper 1 South Africa
                                                                    is a society in transition with a double burden of diseases
                                                                    related to both under- and overnutrition. Poorer populations
E M W Maunder, J Matji, T Hlatshwayo-Molea                          have problems of stunting, micronutrient deficiencies and a
                                                                    greater risk of infectious disease, while both richer and poorer
                                                                    populations are more prone to obesity and chronic
‘Enjoy a variety of foods’ is the first of the ten South African    degenerative diseases.
Food-Based Dietary Guidelines (FBDGs). This guideline
                                                                       ‘Enjoy a variety of foods’ is the first of the ten FBDGs. This
attempts to focus on some of the consequences arising from a
                                                                    guideline attempts to focus on some of the consequences
lack of dietary variety. Its aim is to encourage people to
                                                                    arising from a lack of dietary variety. Results of the 1999
change their diets where necessary so as to increase the
                                                                    National Food Consumption Survey in South Africa showed
variety of foods eaten and to enjoy their food. The guideline
                                                                    that the diets of many households, particularly lower income
needs to be understood in the context of the other FBDGs and
                                                                    households, have low dietary variety.2 The aim of this guideline
to be applied with the assistance of appropriate food guides.
                                                                    is to encourage people to change their diets where necessary so
  For both consumers and nutritional scientists, variety is         as to increase the variety of foods eaten and to enjoy their food.
conceptualised as including different foods and different food      The guideline needs to be understood in the context of the
groups as part of the diet, as well as altering the method of       other FBDGs and to be applied with the assistance of a food
food preparation. In addition, for the consumer, variety is         guide.
important in order for the taste preferences of the household
                                                                      The aim of this paper is to discuss the rationale and scientific
to be accommodated as well as ensuring that the family
                                                                    background for the recommendation to enjoy a variety of
enjoys their food.
                                                                    foods. It should be noted that the FBDGs are for children aged
  Prevalent low micronutrient intakes and low energy                5 years and older and for all ‘healthy’ South African adults
intakes, as well as overconsumption of food with the                (excluding pregnant and lactating women).
associated increased risk for chronic diseases of lifestyle, are
addressed.
                                                                    CONCEPTUALISATION OF THE FBDG ‘ENJOY A
  There are, however, a number of potential problems which          VARIETY OF FOODS’
may arise from this guideline. The high levels of household
food insecurity in South Africa will be a constraint on the         Conceptualisation of dietary variety by nutritional
implementation of this guideline. Increasing dietary variety        scientists
could be interpreted as increasing the number of processed          Nutritional scientists are interested in quantifying and
foods of low micronutrient and phytochemical content,               describing dietary variety because of possible relationships
particularly in the urban context. Obesity is a problem for         between dietary variety and the nutritional quality of the diet
some sections of the population in South Africa and                 and between dietary variety and the health of people
increasing dietary diversity could lead to increased energy         consuming the diet.
intakes and obesity. Therefore, formulation of appropriate
                                                                       Dietary variety can be conceptualised and measured in a
food guides and other measures are important to address
                                                                    number of ways. The choice of index that is used to assess
these problems and to ensure that increasing dietary variety
                                                                    dietary variety is therefore important, since the use of different
leads to increased intakes of appropriate foods that are good
                                                                    indices may lead to different conclusions regarding
sources of micronutrients. The challenge is to ensure that
                                                                    relationships with dietary variety. Two primary approaches
these goals are achieved within the context of high household
                                                                    have been used to create an index of dietary variety. The first is
food insecurity and increasing urbanisation.
                                                                    the calculation of a score based on the numbers of individual
                                                                    foods consumed. The second is to group foods into major and
                                                                    minor food groups, and derive a score based on the number of         S7
                                                                    food groups consumed. 3 A key issue in determining the dietary
Discipline Dietetics and Human Nutrition, University of Natal       variety score is determining which foods should count as the
E M W Maunder, BSc Nutr, PG Dip Diet, PhD                           same or different items. 4
UNICEF, South Africa
                                                                      Nutritional scientists argue that it is useful to examine the
J Matji, BSc Nutr, MSc Nutr
                                                                    diets that people consume in terms of a global index of the
Institute for Human Nutrition, MEDUNSA
                                                                    variety of foods eaten. Human diets are complex. In addition to
T Hlatshwayo-Molea, BSc Diet
                                                             ARTICLES


    examining individual nutrients and other food constituents,           as part of the diet, as well as altering the method of food
    there are many nutrient-nutrient interactions. Therefore, it is       preparation. Nevertheless, nutritional scientists try to define
    difficult to draw conclusions regarding the effects of a single       dietary variety more precisely and quantitatively in order to
    food or nutrient on health outcomes.5 Furthermore, our                enable them to formulate and test hypothesis regarding the
    nutritional knowledge is incomplete, but expanding                    relationship of foods, dietary quality and disease, whereas the
    continuously, both in terms of nutrients and non-nutrients            consumer had a greater emphasis on the taste and enjoyment
    present in food that may impact on public health. Therefore, it       of food, which provides a useful background to the
    is important to advocate the consumption of a variety of foods        formulation of appropriate nutrition education.
    to ensure that there is a positive outcome on health,
    notwithstanding the limitations in our knowledge. In                  DIETARY DISORDERS OF PUBLIC HEALTH
    particular, it is important to ensure that the biodiversity of food   SIGNIFICANCE
    sources is maintained and nutrient-dense foods are consumed.
                                                                          A lack of dietary variety is thought to contribute to:
    Conceptualisation of dietary variety by South                         • low micronutrient intakes
    African consumers                                                     • low energy intakes
    Focus-group discussions with Xhosa, Zulu, Afrikaans and               • chronic diseases of lifestyle.
    English consumers in the KwaZulu-Natal and Western Cape
    provinces of South Africa, among urban (formal and informal)          Low micronutrient intakes
    and rural populations, showed that dietary variety was                Dietary diversification is one of the four main strategies
    conceptualised as including different foods and different food        advocated internationally for the improvement of
    groups as part of the diet. 6 This was achieved both by varying       micronutrient status in undernourished individuals.
    the composition of foods used in each meal as well as varying
                                                                            A guideline on dietary variety has been substantiated in
    the composition of meals from day to day. In addition, in
                                                                          other countries on the basis of the need to consume more than
    households where there are few foods available, altering the
                                                                          40 different essential nutrients. This is felt to be particularly
    method of food preparation was cited as a means of increasing
                                                                          important in relation to nutrients which are found only in a
    dietary variety. All groups thought that the part of the
                                                                          few foods such as vitamin A and its precursors, calcium, iron
    guideline referring to variety was important in order for the
                                                                          and vitamin C. When few such foods are consumed, intakes of
    taste preferences of the household to be accommodated, as well
                                                                          these particular nutrients may be lacking.7
    as ensuring that the family enjoyed their food and received the
    required nutrients.                                                      Data from the 1999 National Food Consumption Survey of
                                                                          children aged 1 - 9 years in South Africa,2 showed that low
      These different interpretations of dietary variety can be
                                                                          income households had only a few foods present in the house,
    viewed as complementary and as addressing differing specific
                                                                          that few foods were consumed by the children and that low
    public health problems.
                                                                          micronutrient intakes were widespread. The same survey
       The word ‘enjoy’ was understood as meaning to be satisfied         showed that the average number of foods consumed in low
    or happy with and liking the food. It is interesting to note that     income households nationally was 8 and varied from 4 in the
    in the situation of household food insecurity, focus-group            Free State to 13 in the Western Cape, indicating a low dietary
    participants talked about enjoying food in the sense of being         variety. The foods found most frequently in the household
    lucky to have food. The focus-group participants also                 inventory of lower income households (< R12 000 per
    understood the term enjoy to refer to enjoying foods which            household per year) were maize, salt, white sugar, tea, fat/oils,
    fitted in with household taste preferences. In addition, it is        white rice and white bread. These foods, together with brown
    interesting to note that household taste preferences could lead       bread and hard margarine, were the foods most frequently
    to the exclusion of certain foods.                                    consumed by all children in the survey on the basis of the
                                                                          24-hour recall (24 HR) method. All other foods listed (24 HR)
   Reflections on the conceptualisation of dietary                        such as chicken, beef, cabbage and squash, were consumed by
   variety by nutritional scientists and by South                         less than a third of the sample, which is important in relation to
S8 African consumers                                                      the low micronutrient intakes reported in the survey. Therefore,
                                                                          there is a need for an increased intake of a variety of foods, e.g.
    It would, therefore, appear that there is much commonality
                                                                          fruits, vegetables, meat and legumes which will also contribute
    between the conceptualisation of dietary variety by nutritional
                                                                          to improving micronutrient status.
    scientists and by South African consumers. In this regard, both
                                                                             Food consumption data from North America have shown
    nutritional scientists and consumers conceptualised dietary
                                                                          that variety in food choices and dietary quality are related.8
    variety as including different foods and different food groups
                                                                          Simply including foods from each of the five major food




    September 2001, Vol. 14, No. 3 SAJCN (Supplement)
                                                         ARTICLES



groups used in the USA(i.e. milk and milk products, grain              Furthermore, two studies in adults, one in France4 and one in
products, fruits, vegetables, meat and meat alternatives)            the USA,12 have shown an association between increased
showed a correlation with the nutritional adequacy, measured         dietary variety and increased energy intake. The former study
as the mean adequacy ratio (MAR), an index of the percentage         used a dietary diversity score based on the number of food
of recommended intake for eleven nutrients:protein, calcium,         groups consumed, while the second study used an index based
iron, magnesium, phosphorus, vitamin A, thiamin, riboflavin,         on the number of different food items consumed within food
and vitamins B 6, B12 and C. The authors suggest that the            groups.
simplest approach to interpreting ‘Enjoy a variety of foods’
may be to include foods from each of the five food groups. The       Chronic degenerative diseases
data also indicate that the addition of only one extra food item     South Africa faces overnutrition-related chronic diseases of
to a diet of poor dietary variety led to a significant increase in   lifestyle such as hypertension, cardiovascular disease, non-
MAR, which was not the case when dietary variety was                 insulin-dependent diabetes mellitus and cancer, which are
initially high.                                                      prevalent in all population groups.
   A similar analysis of the South African National Food
                                                                        The observed relationships between diet and chronic
Consumption Survey data still needs to be done. However,
                                                                     diseases of lifestyle have been investigated. Many studies have
given the low number of food items consumed in the diet from
                                                                     shown that diets high in fruits and vegetables and low in meats
the different food groups, and the low reported micronutrient
                                                                     and fats are protective against the development of chronic
intakes, one can safely state that an increase in the variety of
                                                                     diseases of lifestyle. It is most unfortunate, however, that
food from these food groups will be associated with improved
                                                                     although the relationship shown is based on the consumption
micronutrient intakes in South Africa.
                                                                     of specific foods, both scientists and public health professionals
   This important consideration should be borne in mind in
                                                                     tend to trivialise the importance of wholesome foods by
view of the consumer’s interpretation of increasing dietary
                                                                     concentrating on the individual components of the diet and
variety by altering methods of food preparation. The latter will
                                                                     their chemical nature.14 In terms of nutrition of the public and
not improve the micronutrient intake of the diet where the diet
                                                                     also in terms of scientific understanding, working with foods
consists of a few foods/few food groups and has a low
                                                                     rather than any one of their components has much to be
micronutrient content.
                                                                     recommended. In this regard Wahlqvist and Specht 15 have
Low energy intakes                                                   shown that the food pattern most protective against disease is
                                                                     one of food diversity, which is defined as using probably 20 -
The National Food Consumption Survey 2 showed that there             30 biologically distinct foods in a week.
were widespread low energy intakes in children aged 1 - 9
                                                                       Several investigators have studied the relationship between
years. The number of foods consumed by these children was
                                                                     dietary diversity (measured as an index based on food or food
also low.2 Low energy intakes in developing countries have
                                                                     groups) and disease outcome 3 and many but not all have found
been ascribed to the lack of available food, and also type of
                                                                     an inverse relationship between increased dietary diversity and
foods available, e.g. the low fat content of many African diets.9
                                                                     mortality (all cause), cancer and cardiovascular disease.
   Low energy intakes could be increased by increasing the
                                                                        A r ecent analysis by Kant et al.5 found an inverse correlation
variety of foods eaten. Golden 13 has suggested that nutrients
                                                                     between the Recommended Food Score and all cause mortality
can be divided into types I and II and that deficient intakes of
                                                                     in American adults. The Recommended Food Score is the score
type II nutrients, e.g. zinc, are associated with anorexia. It can
                                                                     derived by comparing the number of foods reported to be
be postulated that a vicious cycle is set up when low dietary
                                                                     eaten at least once a week with those recommended by current
variety is associated with reduced energy and micronutrient
                                                                     dietary guidelines, i.e. fruits, vegetables, whole grains, low fat
intakes and a depression of appetite, further exacerbating the
                                                                     dairy products and lean meats and poultry. The conceptual
low energy intakes. Underwood 10 postulated that part of the
                                                                     framework for the food score is therefore broader than using a
cause of low energy intakes in developing countries is related
                                                                     dietary variety score which only counts the number of foods, as
to the monotomy of the diet. This hypothesis was tested in a
                                                                     suggested by Drewnowski et al.4
clinical study in Peru and the results cited by Brown et al.11
show that in children fed two diets with a similar nutrient            It would seem that in relation to the prevention of chronic
composition the energy intake was increased by 10% when the          diseases of lifestyle, particularly in relation to obesity (see      S9
taste, colour and consistency of the diet was varied. This           below), this guideline must, as is intended, be used in
finding is in line with views expressed by the focus-group           conjunction with the other FBDGs to ensure that there is
studies on consumers in South Africa, that altering the method       sufficient intake of foods containing protective factors and a
of food preparation can also be used as a means of increasing        reduced intake of foods which are known to increase the risk of
dietary variety.6                                                    disease.
                                                             ARTICLES



      POTENTIAL PROBLEMS ARISING FROM THE                                   As stated by Gussow and Clancy,17 ‘The proliferating
      GUIDELINE ‘ENJOY A VARIETY OF FOODS’                               ‘variety’ in the supermarkets does not reflect an equivalent
                                                                         biological variety ... Thus nutritionists must help consumers
      The FBDG work group recognises that there may be a number
                                                                         learn to create a demand for a wider variety of whole foods
      of problems which arise in implementing this guideline,
                                                                         instead of a succession of food novelties whose claim to
      namely:
                                                                         diversity is based on processing techniques and artificial colors
      • The high levels of household food insecurity in South Africa.
                                                                         and flavors.’ This is particularly true in view of the findings of
      • The recommendation of increasing dietary variety could be
                                                                         Bourne,18 which have shown that with migration to urban areas
        misinterpreted as increasing the number of processed foods,
                                                                         in South Africa, increased urban exposure was associated with
        which in the urban context at least, could lead to an increase
                                                                         an increased atherogenicity of the diet of African adults,
        in the consumption of processed foods of poor micronutrient
                                                                         namely an increase in the proportion of energy supplied by fat
        and phytochemical content.
                                                                         and a decrease in the proportion of energy supplied by
      • Increasing dietary diversity could lead to an increased
                                                                         carbohydrate. In terms of foods this was related to a decreased
        dietary energy intake, thereby exacerbating the increasing
                                                                         consumption of dairy foods and cereals and an increased
        prevalence of obesity in certain sections of the South African
                                                                         consumption of meat, and also of non-basic foods or nutrient-
        population.
                                                                         empty foods, such as potato crisps and carbonated drinks. Of
                                                                         further particular interest to the issue of dietary variety is the
      Household food insecurity and other barriers
                                                                         finding of Bourne et al.19 that the urban diet was confined to a
      On the basis of the available evidence there can be little doubt   relatively narrow range of foods, with low intakes of dairy
      that it would be desirable to increase dietary variety of South    products and fruits and vegetables. A later survey involving all
      African diets, particularly of people living in low income         population groups also showed that intakes of dairy products
      households. However, achieving this goal will be most difficult    and fruits and vegetables are low, particularly in Asians,
      for this section of the population because of the constraints of   coloureds and Africans.20
      poverty. There is ample evidence of household food insecurity        The meaning of the guideline should therefore be discussed
      in South Africa when either indirect or direct indicators are      using appropriate food examples.
      used to measure it. May,16 using indirect economic indicators,
      has shown high levels of food insecurity, a finding confirmed      Increase in obesity
      by direct measurement of food present in low income
                                                                         The prevalence of obesity is high among some sections of the
      households by the National Food Consumption Survey.2
                                                                         population in South Africa. Increasing dietary diversity could
        The focus-group studies in KwaZulu-Natal and the Western
                                                                         potentially lead to an increased energy intake and therefore
      Cape also identified affordability as a major constraint,
                                                                         contribute to a further increase in the prevalence of obesity and
      particularly with regard to fruits, vegetables and foods of
                                                                         associated problems such as diabetes mellitus and
      animal origin.6 Other problems were time constraints and
                                                                         cardiovascular disease.
      routine food-purchasing habits.6
                                                                            Studies investigating the effect of increasing the variety of
         Because the high levels of food insecurity in South Africa
                                                                         foods at a meal showed that more food is eaten when dietary
      will make it difficult for people to apply this guideline, the
                                                                         variety is high than if the selection of food is limited.21 Data on
      implementation of the Poverty Alleviation Programme and
                                                                         sensory-specific satiety by Rolls and McDermott,22 suggest that
      promotion of income generation are important prerequisites to
                                                                         increasing dietary variety in a manner which leads to different
      its success. In addition a nutrition education campaign is
                                                                         sensory properties of food does lead to increased energy intake.
      needed for all the guidelines, including this specific one. This
                                                                         While this is desirable in certain situations, e.g. where the
      campaign should be sensitive to financial and other constraints,
                                                                         energy intake is lower than requirements, it is not desirable
      be multisectoral and aim at targeting specific population
                                                                         when it leads to the development of obesity. Rolls 21 warned that
      groups at different levels of socio-economic status.
                                                                         advice to eat a variety of foods might lead to overconsumption
                                                                         of energy. Food consumption data of a large and varied group
      Consumption of processed foods
                                                                         of adults in the USAindicate that increased variety within food
      Particularly in the urban context with an abundance of             groups was also associated with increased body fatness and
S10   processed foods, increasing dietary variety could be               increased energy intakes. Further analysis of the data however
      misinterpreted as increasing the consumption of processed          also showed that this varied within food groups, e.g. increased
      foods. This could be counterproductive in terms of the aim of      variety within the vegetable group was negatively associated
      this recommendation, particularly in relation to increasing        with percentage body fat whereas increased variety within the
      micronutrient intake and changing the proportions of               combined group of sweets, snacks and condiments was
      macronutrient intakes to reduce the risk of chronic                positively associated with the percentage of body fat.12 McCory
      degenerative diseases.                                             et al.12 concluded that a high variety of sweets, snacks,



      September 2001, Vol. 14, No. 3 SAJCN (Supplement)
                                                         ARTICLES



condiments, entrees, and carbohydrates, coupled with a low            References

variety of vegetables, promotes long-term increases in energy          1. Vorster HH, Love P, Browne C. Development of Food-Based Dietary Guidelines for South
                                                                          Africa — the process. S Afr J Clin Nutr 2001; 14: suppl, S3-S6 (this issue).
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therefore, in the USAtheDietary Guideline on variety was                  Children aged 1- 9 years, South Africa . Pretoria:Department of Health, 1999.
                                                                       3. Kant AK. Indexes of overall diet quality:a review.. J Am Diet Assoc 1996; 96: 785-791.
misinterpreted as a licence to consume foods that may not be           4. Drewnowski A, Ahlstrom Henderson S, Shore AB, Fischleer C, Preziosi P, Hercberg S. Diet
considered healthy choices, a scenario to be avoided at all costs         quality and dietary diversity in France: implications for the French paradox. J Am Diet Assoc
                                                                          1996; 96: 663-669.
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                                                                          1999; 69: 350-351.
within certain food groups where energy intake is adequate
                                                                       8. Kreb-Smith SM, Smiciklas-Wright H, Guthrie HA, Krebs-Smith J. The effects of variety of
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                                                                      11. Brown KH, Dewey KG, Allen LH. Complementary Feeding of Young Children in Developing
the guideline on physical activity.                                       Countries: A Review of Current Scientific Knowledge . Geneva:WHO, 1998: 75-76.
                                                                      12. McCory MA, Fuss PJ, McCullum JE, et al. Dietary variety with food groups: association with
                                                                          energy intake and body fatness in adult men and women. Am J Clin Nutr 1999; 69: 440-447.
                                                                      13. Golden MHN. The role of individual nutrient deficiencies in growth retardation of children
RATIONALE FOR THE USE OF THE TERM ‘ENJOY’                                 as exemplified by zinc and protein. In: Waterlow JC, ed. Linear Growth Retardation in Less
                                                                          Developed Countries. New York:Nestle, Vevey/Raven Press, 1988: 143-163.
Guidance given on the implementation and use of FBDGs by              14. Solomons NW. Adult nutrition and cities — an international perspective. S Afr JClin Nutr
                                                                          2000; 13: Suppl 1, S13-S22.
the FAO/WHO consultation24 included the concept that                  15. Wahlquist ML, Specht RL. Food variety and biodiversity:econutrition. Asia Pac JClin Nutr
                                                                          1998; 7: 314-319.
guidelines should be user-friendly and positive without
                                                                      16. May J. Experience and Perceptions of Poverty in South Africa. Durban:Praxis Publishing, 1998.
negative prescriptive clauses. Therefore, in formulating the first    17. Gussouw JD, Clancy KL. Dietary guidelines for sustainability. J Nutr Educ 1986; 18: 1-5.
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                                                                          reference to the nutrition transition. PhD thesis, University of Cape Town, 1996.
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CONCLUSION                                                                Consultation. Nicosia, Cyprus: FAO/WHO, 1996.


The responses obtained from the focus groups of consumers as
well as the thinking of nutrition scientists internationally are in
line with the thinking of the Working Group in drawing up the
guidelines.
  While work on dietary variety is ongoing there is scientific
evidence to support the inclusion of the use of the FBDG ‘Enjoy
a variety of foods’, particularly with regard to increasing
micronutrient and energy intakes and protection against the
development of chronic diseases of lifestyle. However, careful
thought should be given to the formulation of appropriate food
guides and other measures so that increasing dietary variety
does lead to increased intakes of foods from food groups which
are currently infrequently consumed by many South Africans.
This is important to ensure that micronutrient and energy
                                                                                                                                                                          S11
intakes increase where appropriate, and at the same time to
prevent increased energy intake and obesity in those
individuals who already have an adequate energy intake. The
challenge which faces South African nutritional professionals is
to ensure that these goals are achieved within the context of
high household food insecurity and increasing urbanisation.

				
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